Should Congress Have Let the Cuts Stand?

Yesterday's vote on H.R. 6331—the bill to halt a Medicare physician pay reduction—made for great political theater.

Midway through the roll call the Senate stopped the proceedings and stood for a standing ovation that lasted several minutes. In walked Senator Ted Kennedy, for the first time since he was diagnosed with a brain tumor, to belt out an "Aye" in favor of the bill.

After falling one vote shy two weeks ago, the legislation was approved—a great victory for the nation's physicians. Right?

Not according to some physician bloggers. I came across a post at The Happy Hospitalist arguing that it's time to let the cuts stand in order to enact real change. Kevin Pho agrees and says that dropping Medicare en masse, which would possibly happen if the cuts passed, is the closest physicians can get to a strike. Andy at Surgical Diversions sums up the argument best when he writes that "the system needs to undergo some catastrophic collapse before it will get better."

You won't hear these statements coming from physician representatives like the AMA, who have been fighting and lobbying for months (years, really) to stop the cuts. Officially, physicians are celebrating (and assuming that President Bush won't follow through on his threat to veto the legislation).

But it's easy enough to see the hollowness of the victory and the appeal of such a drastic approach.

If the cuts had gone through, the path was clear—physicians would begin opting out of Medicare, and the flaws in the reimbursement system would be exposed. It may be an undesirable outcome, and painful, but at least it would have been a new approach.

Now, the way forward is less certain. Congress has for the umpteenth time patched a band aid on a gaping wound, and physicians are still left with the problem of finding a long-term solution or facing another cut in 2010.

Ultimately, those hoping for cuts to spur reform are a little premature. If Congress is still struggling to stop another payment reduction at the 11th hour in a year and a half, then I can buy the bloggers' arguments and say rip off the band aid, let the cuts go into effect and force the hand. But that 18-month window provides a final chance to change the structure of the payment system, and what happened over the last two weeks proves that it can still be done politically.

In the end, Kennedy's vote was only symbolic. The bill passed 69-30 (with only presidential candidate John McCain absent), and physician lobbying had a lot to do with the swing. Take Senator John Cornyn, one of the Republicans to switch his vote. The Texas Medial Association publicly revoked an endorsement of him after he voted against the bill two weeks ago, and considering his dropping poll numbers and a potentially close reelection bid in the fall, that probably had a lot to do with his change of heart.

All across the country, physician organizations went on the offensive. The AMA broadcast advertisements calling out several Senators who opposed the bill by name. Those who, like Cornyn, face tough reelection bids felt the pressure.

Physicians may feel powerless against the insurance and HMO lobbies, who were the primary parties opposed to the bill, but two things helped them take down the Goliath.

First, they had help—senior citizens organizations (i.e., the AARP) and veterans groups also had a stake in the Medicare bill and lobbied for doctors. Physicians are quickly realizing the value of enlisting patients in their efforts for change. Second, their backs were against the wall, forcing them to put all they had into the effort—they lobbied, spent money, contacted legislators, wrote letters to the editor and op-eds, and talked to their patients.

Payment reform can happen, but physicians can't get too comfortable with this temporary win. They will still be competing against some powerful lobbying forces for Congressional attention. To keep a spot at the table, industry associations and individual physicians should be a little skeptical of this victory—all they really won was pay stagnation, after all.

If the physician community treats every day as if Congress is on the verge of cutting their pay by 10.6%, this might be the last time it is actually a possibility.

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